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Arcelus Martínez JI, Leiva Jiménez B, Ruiz Barrera L, Expósito Ruiz M, Muñoz Pérez N, Villar Del Moral J, Díez Vigil JL, López Espada C. Prophylaxis of venous thromboembolism in general surgery in Spain. Analysis of a national survey. Cir Esp 2020; 98:516-524. [PMID: 32507499 DOI: 10.1016/j.ciresp.2020.04.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/20/2020] [Accepted: 04/26/2020] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) represents a serious postoperative complication that can be prevented by adequate thromboprophylaxis. Surveys provide relevant information about clinician's attitudes and preferences regarding VTE prophylaxis. METHODS Transversal, descriptive study based on a survey sent to general surgeons members of the Spanish Association of Surgeons (AEC), that included 31 questions regarding postoperative VTE and its prevention, as well as three clinical scenarios. RESULTS 530 surgeons, 21.8% of the 2,429 invited by electronic mail to participate, completed the survey. Most of the answering clinicians work on in big teaching hospitals, and 28.5% are residents. VTE represents a serious problem for 28% of participants. Although 81% consider that their knowledge on the prevention of postoperative VTE is adequate, a similar percentage recognizes the need for further education. The vast majority (98.7%) use low molecular weight heparins, which are considered the most effective and safe modality, followed by mechanical methods. The Caprini risk assessment score is used by 81% of surgeons, who usually start pharmacological prophylaxis preoperatively. However, there are remarkable differences in the dosing of heparins, timing of initiation, and duration, especially in non-oncologic surgical patients. CONCLUSIONS Most Spanish surgeons are interested in the prevention of postoperative VTE. Overall, the level of knowledge on thromboprophylaxis is adequate. However, our results indicate that there is a need for better education on relevant practical aspects of prophylaxis that could be achieved by incorporating recommendations from recent guidelines to local hospital-based protocols.
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Maddineni J, Walenga JM, Jeske WP, Hoppensteadt DA, Fareed J, Wahi R, Bick RL. Product Individuality of Commercially Available Low-Molecular-Weight Heparins and Their Generic Versions: Therapeutic Implications. Clin Appl Thromb Hemost 2016; 12:267-76. [PMID: 16959680 DOI: 10.1177/1076029606291434] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The currently available brand-name low-molecular-weight heparins (LMWHs) in the United States include dalteparin (Pfizer), enoxaparin (Aventis), and tinzaparin (Pharmion). Other products available, in Europe, include certoparin (Novartis), reviparin (Abbott), nadroparin (GlaxoSmithkline), and parnaparin (Alpha-Wasserman). Each of these LMWHs has a characteristic molecular weight profile and biological activity in terms of an anti-FXa and anti-FIIa potency. The mean molecular weight of these drugs ranges from 4.0 kDa to 7.0 kDa and the anti-FXa:anti-FIIa ratio ranges from 1.5 to 3.5. These agents may also be characterized by the presence of specific chemical end groups such as 2-O-sulfo-4-enepyranosuronic acid at the nonreducing terminus (enoxaparin) or 2,5-anhydro-D-mannose at the reducing terminus (dalteparin). Further, the component oligosaccharide chains exhibit product-specific distribution profiles. It is now widely accepted that individual LMWHs are chemically unique agents and cannot be interchanged therapeutically. Each commercial LMWH has been individually developed for specific clinical indications, which are dose and product dependent. Recently, several generic LMWHs have become available in India (Cutenox and Markaparin) and South America (dilutol, clenox, dripanina), and three companies have filed for regulatory approval of a generic version of enoxaparin in the United States. As the primary aim of a generic drug is to reduce cost without compromising patient care, a generic drug is required to be chemically and biologically equivalent to the pioneer drug. Because LMWHs represent complex natural mucopolysaccharide drugs that have undergone chemical and enzymatic modifications, physicochemical and biological information in addition to molecular weight and anti-FXa:anti-FIIa ratio should be used to determine generic equivalency to the branded drug. We have utilized a previously reported approach to systematically compare three generic versions of enoxaparin obtained from India and Brazil with the branded enoxaparin (Lovenox) available in the United States. Testing included molecular and structural profiling, evaluation in clot-based and amidolytic anti-FXa and anti-FIIa assays, and heparinase-I digestion profiles. While the molecular profiles (4.8 ± 1.8kD) and anticoagulant potencies as determined by activated partial thromboplastin time (APTT) were comparable for all four agents, the generic products showed variations in the thrombin time (TT) and Heptest assays. Two generic and the branded enoxaparin were readily digested by heparinase-I, losing most of their anticoagulant activity, but one generic product resisted digestion. This may have been due to a unique structural feature in this product. These studies show that, while generic LMWHs may exhibit acceptable molecular weight and anti-FXa profiles, they can exhibit assay-based differences and digestion profiles. Testing in animal models to determine safety, efficacy, and pharmacodynamic parameters may be important to verify equivalence. In order to assure that the generic LMWHs are equivalent to branded LMWHs such that equivalent clinical results are obtained, there is a need to develop clear stepwise guidelines that will establish equivalency in terms of physical, chemical, biochemical, pharmacokinetic, and pharmacodynamic properties for these anticoagulant drugs.
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Fareed J, Bick RL. Are the Current Guidelines for the Acceptance of Generic Low Molecular Weight Heparins Adequate? Clin Appl Thromb Hemost 2016; 9:269-72. [PMID: 14653436 DOI: 10.1177/107602960300900402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Leong W, Hoppensteadt DA. Generic Forms of Low-Molecular-Weight Heparins: Some Practical Considerations. Clin Appl Thromb Hemost 2016; 9:293-7. [PMID: 14653438 DOI: 10.1177/107602960300900404] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This commentary briefly reviews the controversies of therapeutic and generic interchangeability, as they apply to the antithrombotic drug class called low-molecular-weight heparin (LMWH). Recommendations are prepared for the generic LMWH approval process by various regulatory bodies.
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Harenberg J, Walenga J, Torri G, Dahl OE, Drouet L, Fareed J. Update of the recommendations on biosimilar low-molecular-weight heparins from the Scientific Subcommittee on Control of Anticoagulation of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2013; 11:1421-5. [PMID: 23615078 DOI: 10.1111/jth.12269] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Harenberg J, Kalodiki E, Walenga JM. Ensuring safety of biosimilar low-molecular-weight heparins: a consensus statement of the International Union of Angiology . INT ANGIOL 2012; 31:101-104. [PMID: 22466973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Scharschmidt T. Clinically significant thromboembolic disease in orthopedic oncology: An analysis of 986 patients treated with low molecular-weight heparin. J Surg Oncol 2010; 102:549-50. [PMID: 20976725 DOI: 10.1002/jso.21669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Terao E, Daas A, Rautmann G, Buchheit KH. Collaborative study for the establishment of replacement batches of heparin low- molecular-mass for assay biological reference preparations. PHARMEUROPA BIO & SCIENTIFIC NOTES 2010; 2010:30-36. [PMID: 21144487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
A collaborative study was run by the European Directorate for the Quality of Medicines & HealthCare (EDQM) in the context of the Biological Standardisation Programme (BSP), under the aegis of the Council of Europe and the European Commission, to establish replacement batches for the dwindling stocks of the Heparin low-molecular-mass for assay European Pharmacopoeia Biological Reference Preparation (BRP). The replacement batches of BRP are intended to be used in the assays for anti-Xa and anti-IIa activities, as described in the European Pharmacopoeia (Ph. Eur.) monograph Heparins, low-molecular-mass (0828). Three freeze-dried candidate batches were calibrated against the current International Standard (IS) for Heparin, lowmolecular- weight (2nd IS, 01/608). For the purpose of the continuity check between subsequent BRP batches, the current Heparin low-molecular-mass for assay BRP (batch 5) was also included in the test panel. Thirteen official medicines control and manufacturers laboratories from European and non-European countries contributed data. A central statistical analysis of the datasets was performed at the EDQM. On the basis of the results, the 3 candidate materials were assigned a potency of 104 IU/vial for the anti-Xa activity and 31 IU/vial for the anti-IIa activity. Taken into account the preliminary stability data and the results of this collaborative study, the 3 batches of candidate BRP were adopted in June 2010 by the Commission of the Ph. Eur. as Heparin low-molecular-mass for assay BRP batches 6, 7 and 8.
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Bianchini P, Liverani L, Spelta F, Mascellani G, Parma B. Variability of heparins and heterogeneity of low molecular weight heparins. Semin Thromb Hemost 2007; 33:496-502. [PMID: 17629846 DOI: 10.1055/s-2007-982080] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Chemical and physical characteristics, building blocks, constitutive disaccharides, sulfation degree, and biological activities of heparins (UFHs) and of low molecular weight heparins (LMWHs) obtained by different depolymerization processes are examined comparatively in terms of structure characteristics, content of 1,6-anhydro rings, and other fingerprints. The heterogeneity of different LMWHs depends on different manufacturing processes and on particular specifications of pharmacopoeias. The reported examples prove that the variability among samples of LMWHs manufactured by the same process is quite limited. Most of the variability is derived from the parent UFH. In contrast, fingerprint groups and residues are specific to the depolymerization process and their extent can be roughly controlled through the process parameters.
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Messmore HL. Generic and Commercial Low Molecular Weight Heparins. Clin Appl Thromb Hemost 2006; 12:253. [PMID: 16959678 DOI: 10.1177/1076029606290616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Fareed J, Iqbal O, Nader H, Mousa S, Wahi R, Coyne E, Bick RL. Generic low molecular weight heparins: a significant dilemma. Clin Appl Thromb Hemost 2006; 11:363-6. [PMID: 16244760 DOI: 10.1177/107602960501100401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Gray E, Rigsby P, Behr-Gross ME. Collaborative study to establish the Low-molecular-mass heparin for assay--European Pharmacopoeia Biological Reference Preparation. PHARMEUROPA BIO 2004; 2004:59-76. [PMID: 15659286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Thirty laboratories participated in a collaborative study to calibrate replacements for the 1st International Standard for Low Molecular Weight Heparin and the European Pharmacopoeia Low-molecular-mass heparin for assay Biological Reference Preparation. Two freeze-dried materials and one liquid preparation were included in the study. All three samples gave excellent intra- and inter-laboratory variations (majority of mean % geometric coefficient of variation < 10 %) when assayed against the 1st International Standard by both anti-Xa and anti-IIa assays. There were no major differences found between potency estimates using all methods and that obtained using European Pharmacopoeia method only. Overall, this study showed that the differences between the candidates are marginal. Based on the results of the study Sample B, 01/608 was established as the 2nd International Standard for Low Molecular Weight Heparin. Sample A, 01/592 and sample C, the liquid preparation, were established as replacements for the European Pharmacopoeia 'Low-molecular-mass heparin for assay' Biological Reference Preparation.
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Douketis JD, Johnson JA, Turpie AG. Low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin: assessment of a standardized periprocedural anticoagulation regimen. ACTA ACUST UNITED AC 2004; 164:1319-26. [PMID: 15226166 DOI: 10.1001/archinte.164.12.1319] [Citation(s) in RCA: 229] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The treatment of patients at increased risk for arterial thromboembolism who require temporary interruption of warfarin sodium therapy is a common clinical problem. We investigated the efficacy and safety of a standardized periprocedural anticoagulation regimen with low-molecular-weight heparin. METHODS We studied 650 consecutive patients with a mechanical heart valve, chronic atrial fibrillation, or embolic stroke who required interruption of warfarin therapy because of an invasive procedure. Warfarin was stopped 5 or 6 days before the procedure, and patients received subcutaneous dalteparin sodium, 100 IU/kg twice daily, starting 3 days before the procedure. The risk of postprocedural bleeding determined postprocedural anticoagulant management. In patients undergoing a non-high-bleeding-risk procedure who had adequate postprocedural hemostasis, warfarin was resumed on the evening of the procedure, and dalteparin sodium, 100 IU/kg twice daily, was resumed on the next day and continued until the international normalized ratio was 2.0 or more. If postprocedural hemostasis was not secured, the resumption of dalteparin was delayed. In patients undergoing a high-bleeding-risk procedure, warfarin was resumed on the evening of the procedure, but dalteparin was not given after the procedure. RESULTS Patients were followed up during the preprocedural and postprocedural period for a mean of 13.8 days (range, 10-18 days). In 542 patients who underwent a non-high-bleeding-risk procedure, there were 2 thromboembolic events (0.4%), 4 major bleeding episodes (0.7%), and 32 episodes of increased wound-related blood loss that precluded postprocedural dalteparin administration (5.9%). In 108 patients who underwent a high-bleeding-risk procedure, there were 2 deaths (1.8%) possibly due to thromboembolism and 2 major bleeding episodes (1.8%). CONCLUSIONS In patients at increased risk for arterial thromboembolism who require temporary interruption of warfarin therapy, a standardized periprocedural anticoagulant regimen with low-molecular-weight heparin is associated with a low risk of thromboembolic and major bleeding complications.
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Levine GN, Ferguson JJ. Low-molecular-weight heparin during percutaneous coronary interventions: Rationale, results, and recommendations. Catheter Cardiovasc Interv 2003; 60:185-93. [PMID: 14517923 DOI: 10.1002/ccd.10640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Turpie AGG. Choice of low molecular weight heparins. J Thromb Haemost 2003; 1:598. [PMID: 12871475 DOI: 10.1046/j.1538-7836.2003.t01-11-00177.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cimminiello C. Choice of low molecular weight heparins. J Thromb Haemost 2003; 1:596-7. [PMID: 12871473 DOI: 10.1046/j.1538-7836.2003.t01-1-00177.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ginsberg JA, Crowther MA, White RH, Ortel TL. Anticoagulation therapy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2002:339-57. [PMID: 11722992 DOI: 10.1182/asheducation-2001.1.339] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Despite refinements and standardization in the use of anticoagulants, many problems remain for clinicians. Dr. Crowther describes appropriate starting and maintenance doses of warfarin, factors accounting for inter- and intra-observer variability and importantly, the management of the over-anticoagulated patients and bleeding patients. Dr. White compares unfractionated heparin (UFH) and low molecular weight heparin (LMWH) and addresses whether there truly are differences in the efficacy and safety of different LMWH's for both arterial and venous indications. Dr. Ortel discusses the management of the problem patient who requires anticoagulants, the management of heparin-induced thrombocytopenia, the pregnant patient, the obese patient, patients who have renal insufficiency and/or liver disease, patients with malignant disease, and other challenging patient populations.
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Kakkar VV, Hoppenstead DA, Fareed J, Kadziola Z, Scully M, Nakov R, Breddin HK. Randomized trial of different regimens of heparins and in vivo thrombin generation in acute deep vein thrombosis. Blood 2002; 99:1965-70. [PMID: 11877267 DOI: 10.1182/blood.v99.6.1965] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Low-molecular-weight and unfractionated heparins are frequently used to treat venous thromboembolism, but it is not known whether they are equally effective in inhibiting in vivo generation of thrombin. In this multicenter trial, 1048 patients were randomized to intravenous unfractionated heparin (group A), twice daily low-molecular-weight heparin (reviparin) for 1 week (group B), or once daily reviparin for 4 weeks (group C). All patients received vitamin K antagonists. Blood samples withdrawn at the baseline and at weeks 1 and 3 were analyzed using markers of in vivo thrombin generation and other coagulation parameters. During the first 3 weeks symptomatic recurrent deep vein thrombosis-pulmonary embolism (DVT/PE) occurred in 17 (4.5%) of 375 patients in group A compared with 4 (1.0%) of 388 patients in group B, and 9 (2.4%) of 374 patients in group C. Forty percent of patients in group A, 53.4% in group B, and 53.5% in group C showed 30% or greater reduction in thrombus size assessed by venography. Patients in group B had significantly greater reduction in D-dimer, prothrombin fragments 1 and 2 (F1 + 2), endogenous thrombin potential (ETP), and thrombin-antithrombin (TAT) complexes compared to groups A and C. Greater release of tissue factor pathway inhibitor (TFPI) and reduction in levels of thrombin activatable fibrinolysis inhibitor (TAFI) and fibrinogen were significantly more pronounced in group C patients. Reviparin administered twice daily plus vitamin K antagonist is more effective in inhibiting in vivo thrombin generation compared to intravenous unfractionated heparin plus vitamin K antagonist, and reviparin once daily produced significantly higher TFPI release and greater reduction in TAFI and fibrinogen levels.
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Ezekowitz MD. Anticoagulation management of valve replacement patients. THE JOURNAL OF HEART VALVE DISEASE 2002; 11 Suppl 1:S56-60. [PMID: 11843522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Anticoagulation regimens vary according to surgeon, nature of the valve (mechanical or biological), its position and other risk factors for stroke. The American College of Chest Physicians (2001) have made the following recommendations to protect patients with prosthetic heart valves from developing a stroke: (i) For mechanical heart valves: Anticoagulation with Warfarin at an INR range 2-3 for patients with a bileaflet mechanical valve in the aortic position; (ii) in the mitral position, an INR of 2.5-3.5 is recommended; an alternative recommendation is an INR of 2-3 in combination with aspirin (80 mg/day); and (iii) in patients with a mechanical valve and a history of systemic embolization, an INR of 2.5-3.5 combined with low-dose aspirin (80-100 mg) is recommended; when Warfarin therapy is initiated, the doses for patients aged <70 years is 4 mg, and for patients aged >70 years it is 3 mg. While it is important to recognize that the therapeutic range for Warfarin is narrow, recommendations have also been established to manage patients with high INRs and for the temporary discontinuation of anticoagulant therapy when they undergo surgical procedures. Rapid anticoagulation can be achieved either with unfractionated heparin or with low-molecular weight heparin (LMWH). Heparin is initiated with an intravenous bolus of 80 U/kg bodyweight, and an infusion of 18 U/kg/h. The activated thromboplastin time should be 60-80 s. An alternative to intravenous heparin is subcutaneous LMWH, which is prescribed in a mg/kg dose. In the event of valve thrombosis in patients who are hemodynamically unstable, surgical exploration with thrombectomy is indicated, with or without valve replacement. In patients who are hemodynamically stable, thrombolytic therapy is recommended initially.
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Wade WE, Spruill WJ. Cost comparison of tinzaparin versus enoxaparin as deep venous thrombosis prophylaxis in spinal cord injury: preliminary data. Blood Coagul Fibrinolysis 2001; 12:619-25. [PMID: 11734661 DOI: 10.1097/00001721-200112000-00002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Thromboembolic events are major causes of morbidity and mortality in patients with spinal cord injuries. Low molecular weight heparins are recommended as prophylaxis against such events. The purpose of the current study was to perform a cost analysis of tinzaparin versus enoxaparin using published efficacy and safety data as deep vein thrombosis and pulmonary embolism prophylaxis in this population. All published English language articles evaluating either tinzaparin or enoxaparin as pharmacoprophylaxis in spinal cord-injured patients were identified. Data from these studies were subjected to cost-effectiveness analyses followed by sensitivity analyses to determine which agent is the most cost-effective in these patients. Results demonstrated that tinzaparin 3500 U daily and enoxaparin 30 mg every 12 h are both cost-effective agents for thromboembolism prophylaxis in patients with spinal cord injuries.
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Rose P, Bell D, Green ES, Davenport A, Fegan C, Grech H, O'Shaughnessy D, Voke J. The outcome of ambulatory DVT management using a multidisciplinary approach. CLINICAL AND LABORATORY HAEMATOLOGY 2001; 23:301-6. [PMID: 11703412 DOI: 10.1046/j.1365-2257.2001.00403.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Low molecular weight heparins (LMWHs) have been demonstrated to be at least as safe and effective as unfractionated heparin (UFH) in the initial management of deep vein thrombosis (DVT). However, the effectiveness of using LMWH in the ambulatory management of DVT in a 'real-life' setting has yet to be evaluated. This multicentre retrospective study involving 697 patients considers the outcome data of patients under- going ambulatory DVT treatment with tinzaparin (Innohep(R), Leo Pharmaceuticals, Risborough, Buckinghamshire, UK). During the 6 months following presentation, 17 (2.5%) patients had confirmed thromboembolic complications, of which 14 occurred subsequent to the initial LMWH treatment phase ('late'). There were no deaths in this group. Bleeding complications were reported in 23 (3.4%) patients, with 13 of these being classified as 'late'. Of these, two events were considered major resulting in hospitalization and death. Hospitalization for all causes was 6.8% (45 patients) with 32 patients being admitted for thromboembolic or bleeding complications. Overall mortality was 6.7%. These results compare favourably with published clinical trial data. This study demonstrates that ambulatory treatment of proven DVT with LMWH is both safe and effective.
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Prandoni P. Heparins and venous thromboembolism: current practice and future directions. Thromb Haemost 2001; 86:488-98. [PMID: 11487039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Unfractionated heparin (UFH) in adjusted doses and low-molecular-weight heparins (LMWH) in fixed doses are the chosen therapy for the initial treatment of venous thromboembolism. The use of UFH protocols ensures that virtually all patients will promptly achieve the therapeutic range for the activated partial thromboplastin time. However, proper use of UFH requires considerable expertise, can cause inconvenience and has limitations. Unmonitored therapy with subcutaneous LMWH is at least as effective and safe as adjusted-dose UFH, is associated with a considerable reduction of mortality in cancer patients, and permits the treatment of suitable patients in an outpatient setting. LMWH in high prophylactic doses is more effective than UFH and oral anticoagulants for prevention of postoperative venous thrombosis in major orthopedic surgery. Whether thromboprophylaxis should be continued for a few additional weeks after hospital discharge is controversial. LMWH and UFH are equally effective for prevention of postoperative deep-vein thrombosis in cancer patients. In a recent controlled randomized trial, enoxaparin in high prophylactic doses was an effective and safe measure of thromboprophylaxis in ordinary bedridden patients. The efficacy and safety of pentasaccharide (the smallest antithrombin binding sequence of heparin) in the treatment and prevention of venous thromboembolic disorders is currently under investigation.
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Choo JK, Kereiakes DJ. Low molecular weight heparin therapy for percutaneous coronary intervention: a practice in evolution. J Thromb Thrombolysis 2001; 11:235-46. [PMID: 11577263 DOI: 10.1023/a:1011917021686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Unfractionated heparin (UFH) remains the principal antithrombotic agent during percutaneous coronary intervention (PCI) but is associated with significant limitations including an unpredictable anticoagulation dose response, the requirement for frequent monitoring, and transient rebound hypercoagulability. Low molecular weight heparin (LMWH) represents an attractive alternative due to its predictable dose response relationship, superior antithrombotic efficacy and potential for improved clinical safety, and has been used increasingly in patients with acute coronary syndromes prior to coronary angiography. The rationale and existing data regarding the use of LMWH in PCI is summarized and reviewed. Preliminary clinical guidelines for the use of LMWH in the transition from medical stabilization of patients with acute coronary syndromes to invasive management in the catheterization laboratory are presented.
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